Great Tools To Make Advanced Healthcare Decisions

Having been around the block a time or two, I’m not afraid to talk about anything with anyone. I also find significant humor in most situations, which makes me my mother’s child. As she lounged on her death bed, emaciated from cancer, my mother raised her legs in the air and laughed, “My legs are now as skinny as Carolyn’s!” My legs aren’t as skinny any more, although my sense of humor is almost as good as my mentor in the art of laughing – my mother. In this post, in honor of National Healthcare Decisions Day on April 16 and my mother, I share an approach to the difficult conversation about end of life choices.

We all have different experience with death, and familiarity breeds comfort. The more exposure we have to dying people and the actual bodies left behind, the more accepting we become with the concept of death in general. Much of death is sanitized today, which decreases exposure and increases fear of the actual life event. This leads to “bad” deaths, intense emotional and/or physical pain for the patient and family, and costs run amok in our healthcare system. The end to this madness starts with simple conversations.

An Immersion Course in Death

Some careers deal with a lot of death – pathologists are tops on the list after funeral directors. Despite what they have to do, most pathologists are cool people. I know this because I had the pleasure of working in the pathology department during medical school and subsequently entered a residency in pathology before moving on to family medicine.

The first year of pathology training includes six months on the hospital autopsy service. Hospital autopsies are much different than autopsies you see on crime shows. Our job was basically to verify why a person died in the hospital – not very glamorous, but also not as stinky as people found “out in the field.” We would review the chart, perform the autopsy, look at slides of the patient’s tissue, and finally write a report of our findings. I also read the patient’s obituary - I wanted to know the person I was writing a "story" about in my report. I had the honor of performing well over a hundred autopsies that first year and learned a few things:

Many illnesses that cause death are preventable.

Doctors don’t often acknowledge in the chart that a patient is going to die. Did the doctors have the conversations?

The healthcare system provides many futile and unpleasant treatments to patients before they die.

In my second year of residency, I did an autopsy on a 52 year old guy with a large tattoo on his chest which said “Born To Die.” He was a biker dude with a pony tail, a very large gut, and all of his organs encased in layers of fat. Of course his coronary arteries were like sewage pipes full of poop, and his cause of death was indeed a major heart attack. He lived his tattoo fully. Unfortunately, his situation was common, and it should have been the exception. That year I changed my career path to family medicine in the hope I could make a difference in how people lived and how they died. I am an optimist.

Taking care of live people rounded out my comfort with end of life events. Along the way, before turning 40 years old, I experienced the death of my parents and then my college roommate. During that time, I was also lucky to face the possibility of my own death. I highly recommend being incorrectly diagnosed with something that can kill you and then finding out the diagnosis was wrong, because a week of facing death reduces the fear. People who have actually survived serious illness embody this concept vigorously.

And finally… I was almost killed by a tree. I fondly call that event my day of liberation, because the experience made me embrace my one life and live it fully. Now I laugh a heck of a lot more, and don’t get bothered by mean people or bull. If only I could integrate my death experiences into the psyche of others…

A Conversation

Fortunately, not everyone receives an immersion course in death. So how do we replace a lack of experience to create comfort with end of life planning? It all starts with conversation. But we are busy, the discussion is not fun for most, and we don’t know where to start. To help you along, I provide these tips.

Tip #1: Acknowledge that death happens

We all know this, and publicly bringing up the fact to our friends and family opens the door to further conversation. Just saying, “You know, we are all going to get sick and die at some point. I want to make certain I face it the way that is right for me” is all most people need to get started.

There may be some resistance from your loved ones such as, “Oh, it won’t happen for a long time. Why are you talking about it now?” We all have different communication styles, and I’m grateful humor is one of my defaults. If there is resistance, I say with a twinkle in my eye, “Don’t you want to control who gets to wipe your rear-end if you can’t do it yourself?” It works every time. Many people don’t want to discuss end of life situations because it acknowledges a future loss of control. Putting it in a frame of control opens their mind to the possibility they can change the outcome.

The goal of NHDD is to create a day where people can’t escape the conversation about healthcare decision making. On April 16th every year, we will see shout outs from major media and anyone involved with healthcare decision making that encourages healthcare decision discussions. This coming Tuesday, use what you see here and in other media outlets to open the conversation with your family.

Tip #3: Utilize tools to facilitate the discussion

There are many great resources to help the conversation along. The Conversation Project has a great “starter kit” to help you and your family cover most of the bases of what is important.

Another really cool tool is the “Prepare” website. This organization walks you through choosing a medical decision maker, deciding what matters the most to you in making healthcare decisions, and how to tell others about your wishes. It also provides vignettes to learn about situations that may resonate with you. At the end, you are provided with your “Action Plan” for advanced care.

If something horrible happens to you, your healthcare surrogate will need a lot of support. Too often, wishes are second guessed and friends and family put pressure on the surrogate to make decisions not congruent with what you wanted. If you share your wishes with friends and family in addition to your surrogate, everyone is on the same page on what you need done.

I would like to think that on Tuesday, April 16th, National Healthcare Decisions Day, we will all take some time to talk about death after the other certain day in life, National Tax Day on April 15th. Get both pains out of the way and move on to the rest of the year.

I am a physician, financial planner, educator, and I love to tell great stories. The world is too complicated and doesn’t have to be that way. The goal for this blog is to bring simplicity to the two subjects I know best – financial planning and medicine.
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